Unleashing Your Potential
Member Information
NameEmail
AddressDaytime Phone (include area code)
CityStateZipEvening Phone (include area code)
Dental hygiene school attendedStateYear of Graduation
Highest educational level attained: Certificate Associate Baccalaureate Master’s Doctorate
Circle Your Credential:RDHLDHOtherCurrent License #State
To qualify for Active membership, you must have been granted a license to practice. Applications received without a license number will not be processed.
Membership Demographic Information
In an effort to learn more about ADHA members, we would appreciate your assistance with the following information:
Gender: Female Male Birth DateEthnicity (optional)
Hours worked per week in Dental Hygiene:
Primary Position (check one): Clinician Educator Public Health Researcher Administrator/Manager Other
States in which you hold current license(s)License Number(s)Year(s) Issued
Annual DuesMethod of Payment
ADHA $ 196.00 I am enclosing a check payable to ADHA for the amount of
my annual dues. (see TOTAL)
Constituent OH$ 70.00 Please charge my annual dues to my credit card. (see TOTAL)
Local Component OH-04$ 15.00. (CleveDHA) Please enroll me in the Quarterly Payment Plan using my credit card.
(see TOTAL plus additional $12.00 processing fee)
Assessment**$
*Renewing members must opt-into the quarterly payment plan online using your
TOTAL$281.00 existing membership account.
Visit for more information on available payment options.
*ADHA bylaws require all active members belong to national
(ADHA) constituent (state) and component (local area)
organizationsCard Number American Express DISCOVER
Contact ADHA Member Services for correct constituent VISA MASTERCARD
and component dues amounts (312.440.8900)Expiration Date
**Only CO, CT, HI, ID, IL, KS, OR WASignature
Dues are not deductible as a charitable contribution for federal
income tax purposes. They may be deducted as a business expense. I understand that by providing us your credit card information, you hereby agree that ADHA may automatically renew your membership each year by charging the applicable
Send Application to: membership dues fee directly to your credit card. Your membership fee will be charged on an annual or quarterly basis according to the manner you have indicated. Please
Mail: 444 N. Michigan Ave., Suite 3400 Chicago, IL 60611 ensure we have updated credit card information so the renewal may be processed.
If you do not wish to have your dues automatically renewed each year you may opt-out
Phone:312 440.8900 next year.
Apply online at